9 ms·

alcoholic people be blamed or treated?

91 points by brazzy 16y ago

deleted 16y ago
[deleted]
lujz 16y ago
Disregarding glandular, hormonal, or similar problems, obesity is certainly not a disease: http://www.youtube.com/watch?v=RXTq2_3LfXM http://www.youtube.com/watch?v=RXTq2_3LfXM.
- chwahoo 16y ago
  Out of curiosity, did you read the full article? It does a great job in making the point that disease/not disease may not be the right question to ask (which is a good thing because it isn't straightforward to answer).
igravious 16y ago
l;bra (long; but read anyway) Articulately put and yummy intellectual fodder. Thank you for the submission brazzy. Cancer and Obesity should always be "cancers" and "obesities" when we're talking about how we should treat the potential/actual sufferer as it varies from type to type. As pointed out by the article it would seem unhelpful to yell at a cancer patient but we should whine at our kids if they start smoking. Also, as obesity comes in many shapes and sizes maybe do do we know whether Sandy has an underlying genetic condition or whether she likes jam donuts too much. As a commenter to the article said: a lot of the choices a consequentialist would make sound like utilitarian choices. I'm not big on utilitarianism so I guess I'd be leery of consequentialism. I absolutely love the idea of breaking down a complex issue into its component parts. It is interesting how some people use outliers rather than type specimens to try to destroy coherent notions which is really unhelpful. For instance to use the example of disease; obesity fails some of the criteria for disease, thus we need to rethink what disease means for us! Less iPad/Flash submissions and more of this sort of thing would be greatly appreciated :)
- brazzy 16y ago
  Articles on these "rationalist" sites often tend towards a mix of smug superiority about one's ability to analyze other people's supposed biases, and lots of references to pet concepts. I posted this one because it does such an excellent job of analyzing the issue in clear, objective terms.
  - stcredzero 16y ago
    Articles on these "rationalist" sites often tend towards a mix of smug superiority about one's ability to analyze other people's supposed biases, and lots of references to pet concepts. There should be a name for the 1st phenomenon, so that websites can use it as a tag. The latter would be too hard to distinguish from citation, however.
    - derefr 16y ago
      The fact that people get a rush from picking things apart should be encouraged, not made explicit to be, perhaps, the target of ostracism—because it means that more people will pick more things apart. There is the egocentric impulse toward social status at the root of even the scientific method: that just proves the amorality of egocentricity, not the immorality of science.
      - stcredzero 16y ago
        Picking things apart is good. Using a good thing as a justification for smug is usually bad. It's often been noted that the best way to discredit something good is to espouse it badly. How about: The best way to discredit something good is to be a jerk about it. (Disclosure: I'm at least as guilty of this as anyone here!)
        derefr 16y ago
        It's not so much a justification for smug; "justifiable smug" is the goal and the positive acts are the means to achieve it. It's a reward intrinsic (a term from game design), usually known as "gamism" under GNS and the people seeking it "Artisans" under the famous MUD paper on the subject: they seek reward by rebalancing power structures in their favor, and by visceral experience. Combined, these are quite often thought of as "bullying" or "trolling", but not necessarily so—it can also be felt, as the name suggests, while using tools with finesse or performing authoritative power exchanges; surgeons are a good example of someone who has routed gamist reward intrinsics to positive acts. I would interpret the posts you refer to as another. That is all to say, this is the reverse of a fundamental attribution error: this is just how these people are, not something they can change. It's part of their utility function to "satisfy" their urge to smug, just as one would satisfy hunger or sexual arousal. And, if we want these people in our society, we should learn to accept that as long as it's not actively hurting anyone.
rauljara 16y ago
When I was a psych major, we dealt with questions like these all the time. I think the author raises excellent points, but presents a rather limited view of the social pressure that people can exert. "We should blame and stigmatize people for conditions where blame and stigma are the most useful methods for curing or preventing the condition, and we should allow patients to seek treatment whenever it is available and effective." There are many conditions that are susceptible to influence by social pressure, but very rarely are blame and stigma the best means of exerting that influence. In most cases, I'd say they are downright harmful. Take alcoholism. The most effective treatment today for alcoholism is AA. (there are many thing about aa that kind of creep me out, but it is a fact that it has the highest success rate of any course of treatment that has been studied). AA works almost entirely through social influence. But a key component of its social influence is talking about alcoholism as a disease, as something separate from an individual which can be done away with. Talking about alcoholism as a moral failing simply does not help. If you are morally bankrupt, what are the odds of your morally bankrupt self digging your way out of that hole? If you have a disease, though, maybe you can find a cure. Similarly, as a child, people yelling at me that I was a lazy bum just didn't help. My primary reaction was resentment, not shame. Though I had shame, too. Its just not so easy to motivate oneself when feeling like a shameful failure. When I started thing of laziness as a behavior that I happened to have, rather than something that was intrinsic to myself, (i.e., I am being lazy right now, what can I do about it, as opposed to I am lazy), I started being able to have more control over it. Not perfect control, of course, but much more than I had.
- dantheman 16y ago
  I thought Timothy Leary's work with LSD was the most effective way to treat alcoholism.
- jheriko 16y ago
  "Similarly, as a child, people yelling at me that I was a lazy bum just didn't help. My primary reaction was resentment, not shame. Though I had shame, too. Its just not so easy to motivate oneself when feeling like a shameful failure." This varies with personality and situation - I know exactly what you mean because I was shouted at for being fat and lazy as a child and it never did any good, but I can also think of many situations in my own life where the opposite was true and people yelling at me for failing provided the impetus to do better... I think the risk of not doing anything is worse though. If poor behaviour is tolerated, and not given some kind of negative feedback then it can become accepted. I suspect this is part of the obesity problem - if living as a fat person were really horrible less people would be inclined to do it and, at the risk of sounding cruel, if medical help were refused for obesity related problems then the genetic element would take care of itself... I'm fat - and if I die because my heart clogs up with all the byproducts of that fatness then it is my own /stupid/ fault.
jheriko 16y ago
Interesting article. I do object to the medical approaches to obesity, depression etc. it seems a very "un-medical" way to approach the problem and, I'm sorry to say, very American. In many of these cases people do themselves harm through their own actions or inactions - using medicine or surgery to "solve" these problems is curing the symptoms rather than the cause. Having the freedom to do what we want doesn't free us from the consequences of our actions...
- dagw 16y ago
  As a counterpoint, I enjoy skiing. My enjoyment of skiing has directly lead to a fairly serious leg injury. Fortunately surgery completely "cured" this and I was back skiing next season, ready to potentially do more harm to myself as if nothing had happened. Did the doctors do the right thing fixing up my leg or should they have let me walk with a limp for the rest of my life as a consequence of my actions?
  - jheriko 16y ago
    Good point. Its definitely not black and white... but I'd lean on the side of leaving you limping unfortunately. I wonder though - would you ski anyway, if the doctors didn't exist? I'd suspect so... I "feel" that there is some difference between the injury type situation and the self inflected harm of depression or obesity though - its possible to ski without any injuries, but its not possible to put on loads of weight, or take a depressed approach to life without suffering the consequences. I guess I am more inclined to feel sorry for you because the risk from skiing is such that you might have avoided the injury if the situation were more favorable... its more "unlucky" than "inevitable".
    - natrius 16y ago
      If you think depression is a choice, you are incredibly ignorant.
      - jheriko 16y ago
        Thanks for the wealth of information with which to undo my supposed ignorance... I never said its a choice anyway, just that behaviour can cause it... whether its intentional or not is another story, and I'm not going to claim that all depression is not physiological - I'm sure there are real hormonal/neurological problems which lead to depression. My personal experience however is that change in behaviour solved my own depression... so in at least one case it is true. My doctor prescribed me pills and his attitude towards it was unhelpful, despite being very sympathetic and supportive - a good slap round the face about my attitude would have been much more effective. I should probably add that I'm pretty fat, bordering on obese perhaps, but I don't consciously over eat...
latch 16y ago
Honest question: What I don't get about the "obesity is genetic" is, why is the obesity rate climbing? Are obese people proliferating at a quicker pace than before? Are the genes responsible dominant?
- jheriko 16y ago
  Genetics are not the only cause...
- rauljara 16y ago
  Well, with any gene, it takes the proper environmental factors for it to be expressed. So while very few people would argue that height isn't largely genetic, most people also accept that it takes proper nutrition in order to grow tall. So even though height is genetic, and South and North Koreans largely share the same genetics, South Koreans are way taller than North Koreans. The genetic argument for obesity is that in areas of occasional famine, it made evolutionary sense to horde food in your gut, particularly fatty food. Until very recently in human history, there just wasn't that much fatty food for your average citizen to horde. Now there is, particularly because food corporations have realized over time that the fattier the food, the more of it they sell, and those previously advantageous genes are running amok. Not everyone has those genes because in places of plenty, those genes aren't that advantageous. I'd agree that that isn't an entirely convincing argument. But I do think it's part of the story.
  - adrih 16y ago
    Can't we directly conclude from your argument that the obesity epidemy can be entirely solved by fixing the environment, which is probably easier than fixing the genes ? Heroin harms us because of our genetic makeup, yet we don't talk about how heroin-induced illness has genetic causes. We simply try to keep people away from heroin.
    - MichaelSalib 16y ago
      Not necessarily. The point is that given the current environment, some people become obese and others do not. The difference between the two groups may be partly due to genetics. And actually, we do talk about the genetic basis for opioid addiction. I recall one doctor suggesting that a small percentage of the population are born addicted to opioids from birth whereas most people will have greater difficulty developing opioid addiction.
solson 16y ago
Neither, they should be held responsible for their actions. Only a change in their actions can change the outcome. Treatment is a nonsense word in this application. "Treatment" is just a way to use social tricks to get them to make different choices while making them believe it's a disease so they don't resist treatment. Real treatment for alcoholism is a liver transplant. Real treatment for obesity is liposuction. They only way to stop damaging yourself is to take responsibility and stop doing what you've been doing. Telling people they are powerless robs them of their dignity and is an outright lie. The person with the problem is the only one with the power to change! The treatment industry in America is a racket that is mostly based on the AA 12 Steps. At best it has a 5% success rate. (http://www.orange-papers.org/orange-effectiveness.html http://www.orange-papers.org/orange-effectiveness.html) If you want a good book on the subject, read Rational Recovery http://www.amazon.com/Rational-Recovery-Cure-Substance-Addiction/dp/0671528580/ref=sr_1_1?ie=UTF8&s=books&qid=1275311441&sr=8-1 http://www.amazon.com/Rational-Recovery-Cure-Substance-Addic...
- Daniel_Newby 16y ago
  "Neither, they should be held responsible for their actions. Only a change in their actions can change the outcome." Experiments strongly suggest that choice and strength of willpower have little to do with body weight. Controlled overfeeding experiments in humans have demonstrated a wide variation in weight gain. Some people's bodies are simply resistant to storing excess food, while other people's store it avidly and gain weight rapidly. After the overfeeding phase of the experiment finished, they then lost weight rapidly with no perceived effort or exercise of willpower. Meanwhile various nonhuman animal experiments have found that body fat is fairly sensitive to things like gut microbes, details of food composition, and subtle differences in the environment. Not one of these can be changed by simply resolving to eat less. "Real treatment for obesity is liposuction." Obesity is a disorder of food conversion and storage, not body fat. Liposuction causes temporary and cosmetic changes. Real treatment is a drug that alters the brain centers responsible for metabolism and hunger. (And indeed such drugs exist and are spectacularly effective. Unfortunately the existing ones also have spectacular and dangerous side effects, but much better ones are rapidly being developed.)
DanielBMarkham 16y ago
Sometimes I think all interesting questions boil down to semantics. One nit: libertarian (classic, not anti-government) attitudes were described thusly: * People who make good decisions are intrinsically good people and deserve good treatment; people who make bad decisions are intrinsically bad people and deserve bad treatment.* Er no. Libertarian thought tells us that variations in individuals are more important than societal standards. Not that people are "bad" or "good" Taking a determinist consequentialist position allows us to do so more effectively. This strikes me as the difference between an academic argument and a practical one. Academically, sure, the numbers add up. Practically, this is completely terrible advice, for the sole reason that the criteria suggested are not only indeterminate but suffer large variations as applied by different individuals. And offering up some sort of scientific committee or standards for what to blame people for is totally whacked, for reasons I'll leave as an exercise to the reader. I liked the observation that people who condemn others may do so because others have not sacrificed. This fits intuitively with what I have observed. I'd add another detail, though. There is a long tradition in western thought that the individual's struggles with character traits that he or she don't like has value in itself. We always should have a place we would like to be that we cannot attain. Western medicine and ideals, however, seem to feel that if we commonly view one condition as "better" or "worse" than another, some sort of chemical or social intervention is required in order to make people better. This worked great when "worse" = the plague, but the model is falling apart when "worse" = too fat. The types of structures and systems of thought we have set up for the plague do not naturally extend to shyness. The word has stretched too far. I support looking at the necessary and sufficient conditions, but I felt the analysis was loose and incomplete, which led to a muddled set of conclusions.
- steveklabnik 16y ago
  > libertarian (classic, not anti-government) Slightly offtopic, but did you mean 'classic liberal?' I thought original recipe libertarians were anarchists. I only ask because I only recently learned that fact, and found it interesting.
  - loewenskind 16y ago
    In the US "libertarian" means something different than it does... everywhere else.
detcader 16y ago
It's a fairly political question in the US. Emotional people believe in emotional solutions, like the death penalty, physical discipline, healing prayer. Logical people believe in logical solutions, like medicine, research, and education. The main difference that persists is that those approach any issue emotionally will end up ignoring the source of the problem and just attack the result, while the permanent cure is to fix the source.
Goladus 16y ago
The semantic criteria listed in the article for defining 'disease' are not rigorous at all and rules out the following conditions that most people would agree are diseases: Alzheimer's Disease (rule 1) Any STD, like AIDS (rule 2) Any pandemic (rule 3) The Common Cold (rules 2, 3) Scurvy, Rickets (rules 2, 6) Also, I'm skeptical that given a clear medical definition of obesity (or more more likely, metabolic syndrome), that it would fail rule 5.
- fhars 16y ago
  I think you misunderstood the list. It is not a list of normative criteria for the definition of disease, but of descriptive criteria, and not even a list of descriptive criteria for disease, but for uses of the word disease. That is twice removed from what you seem to be seeing here. Your observation that many common conditions fail several of the criteria is exactly the point of the list.
  - Goladus 16y ago
    There is no real point to the list, that's my point. You're exactly right. It's a partial list of some of the ways that people sometimes under certain conditions use the word disease. That would be merely boring except that he compares the list to the far more carefully specified definitions 'rube' and 'blegg' and subsequently uses the list as criteria in the next 3 paragraphs. He treats the list as if it's an actual list of semantic features, when in fact it's not. Ultimately he gives up on the question entirely: So, is obesity really a disease? Well, is Pluto really a planet? Once we state that obesity satisfies some of the criteria but not others, it is meaningless to talk about an additional fact of whether it "really deserves to be a disease" or not. What a waste of time.
araneae 16y ago
Well, in 23andme, my obesity probability is listed under "disease risk" :) Interestingly, the average obesity risk according to 23andme is 59%, which is higher than any other "disease" that 23andme offers risk evaluation for. (Type 2 diabetes comes in 2nd at 18.2%) If something is found in the majority of the population, that sounds less like a disease and more a systemic problem.
anamax 16y ago
It's always good to ask why something is a problem and whose problem it is. In this case, many people are saying "{x} is a problem and I want to help". That's okay, if it stops there. However, many then conclude "people with {x} are obligated to make my help as inexpensive/effective/etc as possible". That's incorrect. The folks with {x} are not obligated to do what the helpers deem appropriate. The helpers are free to refuse to help if the helped don't cooperate, but that's the extent of the helper's power.
c00p3r 16y ago
Everything that is obviously possible to overcome with self-will, patience and persistence - drug addiction and alcoholism (except the last, incurable stage), smoking, obesity, shyness, and especially ignorance - should not be tolerated. Most people didn't even tried. They are just blaming everything and everyone else. There are a few of special cases, like children of dopers or alcoholics, inherited diseases and other genetic disorders, but even in such cases it is possible to improve their conditions with a right effort. btw, in the so-called third world word 'disease' means condition which cannot be reversed or cured, such as AIDS, cancer, liver or kidney damages and so on. Everything else, like a fly or stomach aches are just a changing phenomena like weather. People who cannot stop shooting, drinking, smoking, eating, and passively watching are ignorant, not sick (leaving aside the clinical stages). At least from the point of view of the one who did.
- jamesbritt 16y ago
  "Everything that is obviously possible to overcome with self-will, patience and persistence." There are people who can lower their blood pressure though relaxation and meditation. Should we withhold blood pressure medication? "Most people didn't even tried. They just blaming everything and everyone else." And you know this how? You're just making shit up. "People who cannot stop shooting, drinking, smoking, eating, and avoiding people are ignorant, not sick. At least from the point of view of the one who did." From the POV of one who did that is quite an ignorant opinion.
  - c00p3r 16y ago
    Oh, it could be a long discussion, especially in terms of 'withhold medication'. There are some basics, like the difference between symptoms and their causes. In the cases in which it is possible to deal with causes, not the symptoms, using self-will and altered behavior one should do it. Medications, in most cases, are eliminating the symptoms but not their causes. Prozac and is the best example. The complex of cognitive, behavior and psycho therapies in the sub-clinical cases and with medication in the clinical ones usually help, while just a medication without changing the habits will probably fail.
- 16y ago
dennisgorelik 16y ago
Blaming fat/alcoholic is part of the treatment. It works, because blame gives ill individual additional reason to fix the problem. Blame can backfire, so it should be used with caution.
Dove 16y ago
I applaud the author's instincts: when you're not sure whether something really is an X, and hence deserves Y, the right thing to do is unpack the definition of X and ask what about it implies Y in the first place. In logic, definitions may have hard edges, but in real life the edges are fuzzy. Is a sham marriage really a marriage? It depends on why you want to know. The answer changes depending on whether you want to seduce the wife, settle a tax dispute, or research domestic social patterns. The author stops short of really applying this approach. He rightly unpacks the definition of disease and observes that obesity only partially satisfies it. But he then discards the definition as useless and regresses all the way to first principles! You don't want to do that. That definition embeds some wisdom; there's got to be a reason we have it, after all. The next step is to ask which bits of the definition are relevant to the question at hand and see how well obesity satisfies those bits. The question he should be asking is not merely "What is a disease?" but rather "What is it about disease that warrants sympathy or treatment?" The framing of deontology and consequentialism is particularly poor, and I find it unfair to the deontologist. (It is certainly quite silly to say the deontologist is trying to distinguish good from bad people. It's just a way of thinking about ethics, man, not a religion.) I would say that deontology says intentions matter and some actions are inherently bad, while consequentialism says results matter and some conditions are inherently bad. It is unfair to the deontologist to paint him as ignoring consequences; inasmuch as they can be known, they count as intentions. And it is unfair to the consequentialist to paint him as ignoring character; inasmuch as effects on character can be controlled, they count as results. Allow the two philosophies to account for all the known facts, and you'll find they give you very similar answers. So, what's the difference between a disease and a character flaw? Why does the one warrant sympathy and the other warrant reproach? Why should the one be treated and the other conquered? Asked that way, the answer is obvious. Diseases are unpleasant and involuntary -- simple misfortune. Treatment and sympathy are how you alleviate the misery, and there's no more to the story. But character flaws are more complex. They degenerate and run in packs. A sick person doesn't get new diseases, but a person with poor self control definitely accumulates problems. A person needs to conquer himself, conquer his problems, or he will lose his ability to do so. So our efforts are targeted at motivation. The misery of the situation is a mixed blessing: it sucks to experience, but it also teaches you consequences in a way you'll take seriously and motivates you to change. Quick and easy treatment can be counterproductive, and reproach can be useful to briefly raise the pain above the decision threshold--to shock the boiling frog so he jumps. (I say "can be" because people are always complicated...) The distinction is critical. Treating a disease is the right thing to do, but treating a character flaw actually does damage. We need to avoid using a fire extinguisher on a flood or throwing an inflatable life raft on a house fire. So is obesity more like a disease or more like a character flaw? It depends on the case! It can be either or neither or both. I know someone who is a very large woman--beautiful, self-confident, merry, old and full of life. "Eat right, exercise, die anyway," she might say. As an intentional choice, her obesity is not a character flaw. And it's certainly not a disease. She needs neither treatment nor motivation, sympathy nor reproach. The right reaction is to respect her right to make her own decisions, and not call it a problem if she doesn't think it is one. I know someone who just had a baby and is carrying a lot of pregnancy weight. She is generally a motivated and disciplined person, and hates being so fat. She misses her old clothes and her old lifestyle. In this case, the obesity is most like a simple disease--unintended (if not exactly unforeseen), a simple misery. Sympathy is appropriate, and if there were an easy medical fix, it would do no harm. Then again, look at that same woman a few months later. After a good stab at a diet, losing fifteen pounds, she succumbed to stress and sleep deprivation, abandoning the diet in an attempt to stay sane. Months passed. She built eating habits she didn't want, regained much of the weight she'd lost. Life improved, she started getting sleep, and she didn't go back on her diet. She became more used to her condition, though still unhappy about it, and the simple inertia of the circumstance left her with little motivation to change. What had originally become a simple disease was gradually becoming a character problem; she will need to ultimately address it or risk doing damage to her disciplined nature. Perhaps she still deserves sympathy, but a raised eyebrow when she goes for a second bowl of ice cream would probably do more good than harm. A quick medical fix might not help anymore (and might indeed do harm); she has habits that need to change, and only she can do that. People are complex. That's the real moral here. Just as "disease" has a definition with fuzzy boundaries, obesity is not all the same. Understanding whether it is a disease means modeling the individual case and understanding the causes and effects and consequences. Reality is almost always more complex than our definitions. The important thing is to learn to ask the right questions.
rjett 16y ago
Understanding why many of these controversial diseases are problems in the first place is made a little clearer if we look at the problem through the lens of behavioural economics. Alcoholics, nicotine addicts, many obese people, sexaholics, etc place huge discount rates on future rewards so that in the present, these future rewards are almost worthless. Put another way, these people place the most value on their next item of consumption which allows them to overcome the long-term costs of their destructive behaviour or the long-term benefits to quitting (if we assume these people make an instantaneous cost-benefit analysis each time they eat/drink/smoke/etc). This sort of radical discounting behaviour has been shown to be reversible in those who seek treatment. Now, to one of the main points of the article: What constitutes an acceptable form of treatment to these gray-area diseases? An economist would probably say that you would have to consider the individual in question and then formulate a solution based on that individual's preferences, likelihood of success, and cost of change. For one obese person, gastric bypass might be the only solution between life and death. For another obese person, paying $25,000 for gastric bypass surgery might be "worth it" and allow them to change their eating habits in a way that would benefit them long-term without having to go through the anguish of months or years of diet and exercise. For another obese person with another preference set, diet and exercise would be far less costly than gastric bypass. Why bring right and wrong into the argument when looking at treatment methods? Edit: Giving the issue some further thought, some might make a value judgement as to how bad or good heavy temporal discounting is. Given the assumption that it is wrong or bad, then you could hypothesize that the American culture of consumerism has gradually conditioned our population as a whole to shift their preferences to the present, valuing the quick fix over long-term, less costly approaches.

91 points by brazzy 16y ago

deleted 16y ago

[deleted]

lujz 16y ago

Disregarding glandular, hormonal, or similar problems, obesity is certainly not a disease: http://www.youtube.com/watch?v=RXTq2_3LfXM http://www.youtube.com/watch?v=RXTq2_3LfXM.

chwahoo 16y ago
Out of curiosity, did you read the full article? It does a great job in making the point that disease/not disease may not be the right question to ask (which is a good thing because it isn't straightforward to answer).

igravious 16y ago

l;bra (long; but read anyway) Articulately put and yummy intellectual fodder. Thank you for the submission brazzy. Cancer and Obesity should always be "cancers" and "obesities" when we're talking about how we should treat the potential/actual sufferer as it varies from type to type. As pointed out by the article it would seem unhelpful to yell at a cancer patient but we should whine at our kids if they start smoking. Also, as obesity comes in many shapes and sizes maybe do do we know whether Sandy has an underlying genetic condition or whether she likes jam donuts too much. As a commenter to the article said: a lot of the choices a consequentialist would make sound like utilitarian choices. I'm not big on utilitarianism so I guess I'd be leery of consequentialism. I absolutely love the idea of breaking down a complex issue into its component parts. It is interesting how some people use outliers rather than type specimens to try to destroy coherent notions which is really unhelpful. For instance to use the example of disease; obesity fails some of the criteria for disease, thus we need to rethink what disease means for us! Less iPad/Flash submissions and more of this sort of thing would be greatly appreciated :)

brazzy 16y ago
Articles on these "rationalist" sites often tend towards a mix of smug superiority about one's ability to analyze other people's supposed biases, and lots of references to pet concepts. I posted this one because it does such an excellent job of analyzing the issue in clear, objective terms.
- stcredzero 16y ago
  Articles on these "rationalist" sites often tend towards a mix of smug superiority about one's ability to analyze other people's supposed biases, and lots of references to pet concepts. There should be a name for the 1st phenomenon, so that websites can use it as a tag. The latter would be too hard to distinguish from citation, however.
  - derefr 16y ago
    The fact that people get a rush from picking things apart should be encouraged, not made explicit to be, perhaps, the target of ostracism—because it means that more people will pick more things apart. There is the egocentric impulse toward social status at the root of even the scientific method: that just proves the amorality of egocentricity, not the immorality of science.
    - stcredzero 16y ago
      Picking things apart is good. Using a good thing as a justification for smug is usually bad. It's often been noted that the best way to discredit something good is to espouse it badly. How about: The best way to discredit something good is to be a jerk about it. (Disclosure: I'm at least as guilty of this as anyone here!)
      - derefr 16y ago
        It's not so much a justification for smug; "justifiable smug" is the goal and the positive acts are the means to achieve it. It's a reward intrinsic (a term from game design), usually known as "gamism" under GNS and the people seeking it "Artisans" under the famous MUD paper on the subject: they seek reward by rebalancing power structures in their favor, and by visceral experience. Combined, these are quite often thought of as "bullying" or "trolling", but not necessarily so—it can also be felt, as the name suggests, while using tools with finesse or performing authoritative power exchanges; surgeons are a good example of someone who has routed gamist reward intrinsics to positive acts. I would interpret the posts you refer to as another. That is all to say, this is the reverse of a fundamental attribution error: this is just how these people are, not something they can change. It's part of their utility function to "satisfy" their urge to smug, just as one would satisfy hunger or sexual arousal. And, if we want these people in our society, we should learn to accept that as long as it's not actively hurting anyone.

rauljara 16y ago

When I was a psych major, we dealt with questions like these all the time. I think the author raises excellent points, but presents a rather limited view of the social pressure that people can exert. "We should blame and stigmatize people for conditions where blame and stigma are the most useful methods for curing or preventing the condition, and we should allow patients to seek treatment whenever it is available and effective." There are many conditions that are susceptible to influence by social pressure, but very rarely are blame and stigma the best means of exerting that influence. In most cases, I'd say they are downright harmful. Take alcoholism. The most effective treatment today for alcoholism is AA. (there are many thing about aa that kind of creep me out, but it is a fact that it has the highest success rate of any course of treatment that has been studied). AA works almost entirely through social influence. But a key component of its social influence is talking about alcoholism as a disease, as something separate from an individual which can be done away with. Talking about alcoholism as a moral failing simply does not help. If you are morally bankrupt, what are the odds of your morally bankrupt self digging your way out of that hole? If you have a disease, though, maybe you can find a cure. Similarly, as a child, people yelling at me that I was a lazy bum just didn't help. My primary reaction was resentment, not shame. Though I had shame, too. Its just not so easy to motivate oneself when feeling like a shameful failure. When I started thing of laziness as a behavior that I happened to have, rather than something that was intrinsic to myself, (i.e., I am being lazy right now, what can I do about it, as opposed to I am lazy), I started being able to have more control over it. Not perfect control, of course, but much more than I had.

dantheman 16y ago
I thought Timothy Leary's work with LSD was the most effective way to treat alcoholism.
jheriko 16y ago
"Similarly, as a child, people yelling at me that I was a lazy bum just didn't help. My primary reaction was resentment, not shame. Though I had shame, too. Its just not so easy to motivate oneself when feeling like a shameful failure." This varies with personality and situation - I know exactly what you mean because I was shouted at for being fat and lazy as a child and it never did any good, but I can also think of many situations in my own life where the opposite was true and people yelling at me for failing provided the impetus to do better... I think the risk of not doing anything is worse though. If poor behaviour is tolerated, and not given some kind of negative feedback then it can become accepted. I suspect this is part of the obesity problem - if living as a fat person were really horrible less people would be inclined to do it and, at the risk of sounding cruel, if medical help were refused for obesity related problems then the genetic element would take care of itself... I'm fat - and if I die because my heart clogs up with all the byproducts of that fatness then it is my own /stupid/ fault.

jheriko 16y ago

Interesting article. I do object to the medical approaches to obesity, depression etc. it seems a very "un-medical" way to approach the problem and, I'm sorry to say, very American. In many of these cases people do themselves harm through their own actions or inactions - using medicine or surgery to "solve" these problems is curing the symptoms rather than the cause. Having the freedom to do what we want doesn't free us from the consequences of our actions...

dagw 16y ago
As a counterpoint, I enjoy skiing. My enjoyment of skiing has directly lead to a fairly serious leg injury. Fortunately surgery completely "cured" this and I was back skiing next season, ready to potentially do more harm to myself as if nothing had happened. Did the doctors do the right thing fixing up my leg or should they have let me walk with a limp for the rest of my life as a consequence of my actions?
- jheriko 16y ago
  Good point. Its definitely not black and white... but I'd lean on the side of leaving you limping unfortunately. I wonder though - would you ski anyway, if the doctors didn't exist? I'd suspect so... I "feel" that there is some difference between the injury type situation and the self inflected harm of depression or obesity though - its possible to ski without any injuries, but its not possible to put on loads of weight, or take a depressed approach to life without suffering the consequences. I guess I am more inclined to feel sorry for you because the risk from skiing is such that you might have avoided the injury if the situation were more favorable... its more "unlucky" than "inevitable".
  - natrius 16y ago
    If you think depression is a choice, you are incredibly ignorant.
    - jheriko 16y ago
      Thanks for the wealth of information with which to undo my supposed ignorance... I never said its a choice anyway, just that behaviour can cause it... whether its intentional or not is another story, and I'm not going to claim that all depression is not physiological - I'm sure there are real hormonal/neurological problems which lead to depression. My personal experience however is that change in behaviour solved my own depression... so in at least one case it is true. My doctor prescribed me pills and his attitude towards it was unhelpful, despite being very sympathetic and supportive - a good slap round the face about my attitude would have been much more effective. I should probably add that I'm pretty fat, bordering on obese perhaps, but I don't consciously over eat...

latch 16y ago

Honest question: What I don't get about the "obesity is genetic" is, why is the obesity rate climbing? Are obese people proliferating at a quicker pace than before? Are the genes responsible dominant?

jheriko 16y ago
Genetics are not the only cause...
rauljara 16y ago
Well, with any gene, it takes the proper environmental factors for it to be expressed. So while very few people would argue that height isn't largely genetic, most people also accept that it takes proper nutrition in order to grow tall. So even though height is genetic, and South and North Koreans largely share the same genetics, South Koreans are way taller than North Koreans. The genetic argument for obesity is that in areas of occasional famine, it made evolutionary sense to horde food in your gut, particularly fatty food. Until very recently in human history, there just wasn't that much fatty food for your average citizen to horde. Now there is, particularly because food corporations have realized over time that the fattier the food, the more of it they sell, and those previously advantageous genes are running amok. Not everyone has those genes because in places of plenty, those genes aren't that advantageous. I'd agree that that isn't an entirely convincing argument. But I do think it's part of the story.
- adrih 16y ago
  Can't we directly conclude from your argument that the obesity epidemy can be entirely solved by fixing the environment, which is probably easier than fixing the genes ? Heroin harms us because of our genetic makeup, yet we don't talk about how heroin-induced illness has genetic causes. We simply try to keep people away from heroin.
  - MichaelSalib 16y ago
    Not necessarily. The point is that given the current environment, some people become obese and others do not. The difference between the two groups may be partly due to genetics. And actually, we do talk about the genetic basis for opioid addiction. I recall one doctor suggesting that a small percentage of the population are born addicted to opioids from birth whereas most people will have greater difficulty developing opioid addiction.

solson 16y ago

Neither, they should be held responsible for their actions. Only a change in their actions can change the outcome. Treatment is a nonsense word in this application. "Treatment" is just a way to use social tricks to get them to make different choices while making them believe it's a disease so they don't resist treatment. Real treatment for alcoholism is a liver transplant. Real treatment for obesity is liposuction. They only way to stop damaging yourself is to take responsibility and stop doing what you've been doing. Telling people they are powerless robs them of their dignity and is an outright lie. The person with the problem is the only one with the power to change! The treatment industry in America is a racket that is mostly based on the AA 12 Steps. At best it has a 5% success rate. (http://www.orange-papers.org/orange-effectiveness.html http://www.orange-papers.org/orange-effectiveness.html) If you want a good book on the subject, read Rational Recovery http://www.amazon.com/Rational-Recovery-Cure-Substance-Addiction/dp/0671528580/ref=sr_1_1?ie=UTF8&s=books&qid=1275311441&sr=8-1 http://www.amazon.com/Rational-Recovery-Cure-Substance-Addic...

Daniel_Newby 16y ago
"Neither, they should be held responsible for their actions. Only a change in their actions can change the outcome." Experiments strongly suggest that choice and strength of willpower have little to do with body weight. Controlled overfeeding experiments in humans have demonstrated a wide variation in weight gain. Some people's bodies are simply resistant to storing excess food, while other people's store it avidly and gain weight rapidly. After the overfeeding phase of the experiment finished, they then lost weight rapidly with no perceived effort or exercise of willpower. Meanwhile various nonhuman animal experiments have found that body fat is fairly sensitive to things like gut microbes, details of food composition, and subtle differences in the environment. Not one of these can be changed by simply resolving to eat less. "Real treatment for obesity is liposuction." Obesity is a disorder of food conversion and storage, not body fat. Liposuction causes temporary and cosmetic changes. Real treatment is a drug that alters the brain centers responsible for metabolism and hunger. (And indeed such drugs exist and are spectacularly effective. Unfortunately the existing ones also have spectacular and dangerous side effects, but much better ones are rapidly being developed.)

DanielBMarkham 16y ago

Sometimes I think all interesting questions boil down to semantics. One nit: libertarian (classic, not anti-government) attitudes were described thusly: * People who make good decisions are intrinsically good people and deserve good treatment; people who make bad decisions are intrinsically bad people and deserve bad treatment.* Er no. Libertarian thought tells us that variations in individuals are more important than societal standards. Not that people are "bad" or "good" Taking a determinist consequentialist position allows us to do so more effectively. This strikes me as the difference between an academic argument and a practical one. Academically, sure, the numbers add up. Practically, this is completely terrible advice, for the sole reason that the criteria suggested are not only indeterminate but suffer large variations as applied by different individuals. And offering up some sort of scientific committee or standards for what to blame people for is totally whacked, for reasons I'll leave as an exercise to the reader. I liked the observation that people who condemn others may do so because others have not sacrificed. This fits intuitively with what I have observed. I'd add another detail, though. There is a long tradition in western thought that the individual's struggles with character traits that he or she don't like has value in itself. We always should have a place we would like to be that we cannot attain. Western medicine and ideals, however, seem to feel that if we commonly view one condition as "better" or "worse" than another, some sort of chemical or social intervention is required in order to make people better. This worked great when "worse" = the plague, but the model is falling apart when "worse" = too fat. The types of structures and systems of thought we have set up for the plague do not naturally extend to shyness. The word has stretched too far. I support looking at the necessary and sufficient conditions, but I felt the analysis was loose and incomplete, which led to a muddled set of conclusions.

steveklabnik 16y ago
> libertarian (classic, not anti-government) Slightly offtopic, but did you mean 'classic liberal?' I thought original recipe libertarians were anarchists. I only ask because I only recently learned that fact, and found it interesting.
- loewenskind 16y ago
  In the US "libertarian" means something different than it does... everywhere else.

detcader 16y ago

It's a fairly political question in the US. Emotional people believe in emotional solutions, like the death penalty, physical discipline, healing prayer. Logical people believe in logical solutions, like medicine, research, and education. The main difference that persists is that those approach any issue emotionally will end up ignoring the source of the problem and just attack the result, while the permanent cure is to fix the source.

Goladus 16y ago

The semantic criteria listed in the article for defining 'disease' are not rigorous at all and rules out the following conditions that most people would agree are diseases: Alzheimer's Disease (rule 1) Any STD, like AIDS (rule 2) Any pandemic (rule 3) The Common Cold (rules 2, 3) Scurvy, Rickets (rules 2, 6) Also, I'm skeptical that given a clear medical definition of obesity (or more more likely, metabolic syndrome), that it would fail rule 5.

fhars 16y ago
I think you misunderstood the list. It is not a list of normative criteria for the definition of disease, but of descriptive criteria, and not even a list of descriptive criteria for disease, but for uses of the word disease. That is twice removed from what you seem to be seeing here. Your observation that many common conditions fail several of the criteria is exactly the point of the list.
- Goladus 16y ago
  There is no real point to the list, that's my point. You're exactly right. It's a partial list of some of the ways that people sometimes under certain conditions use the word disease. That would be merely boring except that he compares the list to the far more carefully specified definitions 'rube' and 'blegg' and subsequently uses the list as criteria in the next 3 paragraphs. He treats the list as if it's an actual list of semantic features, when in fact it's not. Ultimately he gives up on the question entirely: So, is obesity really a disease? Well, is Pluto really a planet? Once we state that obesity satisfies some of the criteria but not others, it is meaningless to talk about an additional fact of whether it "really deserves to be a disease" or not. What a waste of time.

araneae 16y ago

Well, in 23andme, my obesity probability is listed under "disease risk" :) Interestingly, the average obesity risk according to 23andme is 59%, which is higher than any other "disease" that 23andme offers risk evaluation for. (Type 2 diabetes comes in 2nd at 18.2%) If something is found in the majority of the population, that sounds less like a disease and more a systemic problem.

anamax 16y ago

It's always good to ask why something is a problem and whose problem it is. In this case, many people are saying "{x} is a problem and I want to help". That's okay, if it stops there. However, many then conclude "people with {x} are obligated to make my help as inexpensive/effective/etc as possible". That's incorrect. The folks with {x} are not obligated to do what the helpers deem appropriate. The helpers are free to refuse to help if the helped don't cooperate, but that's the extent of the helper's power.

c00p3r 16y ago

Everything that is obviously possible to overcome with self-will, patience and persistence - drug addiction and alcoholism (except the last, incurable stage), smoking, obesity, shyness, and especially ignorance - should not be tolerated. Most people didn't even tried. They are just blaming everything and everyone else. There are a few of special cases, like children of dopers or alcoholics, inherited diseases and other genetic disorders, but even in such cases it is possible to improve their conditions with a right effort. btw, in the so-called third world word 'disease' means condition which cannot be reversed or cured, such as AIDS, cancer, liver or kidney damages and so on. Everything else, like a fly or stomach aches are just a changing phenomena like weather. People who cannot stop shooting, drinking, smoking, eating, and passively watching are ignorant, not sick (leaving aside the clinical stages). At least from the point of view of the one who did.

jamesbritt 16y ago
"Everything that is obviously possible to overcome with self-will, patience and persistence." There are people who can lower their blood pressure though relaxation and meditation. Should we withhold blood pressure medication? "Most people didn't even tried. They just blaming everything and everyone else." And you know this how? You're just making shit up. "People who cannot stop shooting, drinking, smoking, eating, and avoiding people are ignorant, not sick. At least from the point of view of the one who did." From the POV of one who did that is quite an ignorant opinion.
- c00p3r 16y ago
  Oh, it could be a long discussion, especially in terms of 'withhold medication'. There are some basics, like the difference between symptoms and their causes. In the cases in which it is possible to deal with causes, not the symptoms, using self-will and altered behavior one should do it. Medications, in most cases, are eliminating the symptoms but not their causes. Prozac and is the best example. The complex of cognitive, behavior and psycho therapies in the sub-clinical cases and with medication in the clinical ones usually help, while just a medication without changing the habits will probably fail.
16y ago

dennisgorelik 16y ago

Blaming fat/alcoholic is part of the treatment. It works, because blame gives ill individual additional reason to fix the problem. Blame can backfire, so it should be used with caution.

Dove 16y ago

I applaud the author's instincts: when you're not sure whether something really is an X, and hence deserves Y, the right thing to do is unpack the definition of X and ask what about it implies Y in the first place. In logic, definitions may have hard edges, but in real life the edges are fuzzy. Is a sham marriage really a marriage? It depends on why you want to know. The answer changes depending on whether you want to seduce the wife, settle a tax dispute, or research domestic social patterns. The author stops short of really applying this approach. He rightly unpacks the definition of disease and observes that obesity only partially satisfies it. But he then discards the definition as useless and regresses all the way to first principles! You don't want to do that. That definition embeds some wisdom; there's got to be a reason we have it, after all. The next step is to ask which bits of the definition are relevant to the question at hand and see how well obesity satisfies those bits. The question he should be asking is not merely "What is a disease?" but rather "What is it about disease that warrants sympathy or treatment?" The framing of deontology and consequentialism is particularly poor, and I find it unfair to the deontologist. (It is certainly quite silly to say the deontologist is trying to distinguish good from bad people. It's just a way of thinking about ethics, man, not a religion.) I would say that deontology says intentions matter and some actions are inherently bad, while consequentialism says results matter and some conditions are inherently bad. It is unfair to the deontologist to paint him as ignoring consequences; inasmuch as they can be known, they count as intentions. And it is unfair to the consequentialist to paint him as ignoring character; inasmuch as effects on character can be controlled, they count as results. Allow the two philosophies to account for all the known facts, and you'll find they give you very similar answers. So, what's the difference between a disease and a character flaw? Why does the one warrant sympathy and the other warrant reproach? Why should the one be treated and the other conquered? Asked that way, the answer is obvious. Diseases are unpleasant and involuntary -- simple misfortune. Treatment and sympathy are how you alleviate the misery, and there's no more to the story. But character flaws are more complex. They degenerate and run in packs. A sick person doesn't get new diseases, but a person with poor self control definitely accumulates problems. A person needs to conquer himself, conquer his problems, or he will lose his ability to do so. So our efforts are targeted at motivation. The misery of the situation is a mixed blessing: it sucks to experience, but it also teaches you consequences in a way you'll take seriously and motivates you to change. Quick and easy treatment can be counterproductive, and reproach can be useful to briefly raise the pain above the decision threshold--to shock the boiling frog so he jumps. (I say "can be" because people are always complicated...) The distinction is critical. Treating a disease is the right thing to do, but treating a character flaw actually does damage. We need to avoid using a fire extinguisher on a flood or throwing an inflatable life raft on a house fire. So is obesity more like a disease or more like a character flaw? It depends on the case! It can be either or neither or both. I know someone who is a very large woman--beautiful, self-confident, merry, old and full of life. "Eat right, exercise, die anyway," she might say. As an intentional choice, her obesity is not a character flaw. And it's certainly not a disease. She needs neither treatment nor motivation, sympathy nor reproach. The right reaction is to respect her right to make her own decisions, and not call it a problem if she doesn't think it is one. I know someone who just had a baby and is carrying a lot of pregnancy weight. She is generally a motivated and disciplined person, and hates being so fat. She misses her old clothes and her old lifestyle. In this case, the obesity is most like a simple disease--unintended (if not exactly unforeseen), a simple misery. Sympathy is appropriate, and if there were an easy medical fix, it would do no harm. Then again, look at that same woman a few months later. After a good stab at a diet, losing fifteen pounds, she succumbed to stress and sleep deprivation, abandoning the diet in an attempt to stay sane. Months passed. She built eating habits she didn't want, regained much of the weight she'd lost. Life improved, she started getting sleep, and she didn't go back on her diet. She became more used to her condition, though still unhappy about it, and the simple inertia of the circumstance left her with little motivation to change. What had originally become a simple disease was gradually becoming a character problem; she will need to ultimately address it or risk doing damage to her disciplined nature. Perhaps she still deserves sympathy, but a raised eyebrow when she goes for a second bowl of ice cream would probably do more good than harm. A quick medical fix might not help anymore (and might indeed do harm); she has habits that need to change, and only she can do that. People are complex. That's the real moral here. Just as "disease" has a definition with fuzzy boundaries, obesity is not all the same. Understanding whether it is a disease means modeling the individual case and understanding the causes and effects and consequences. Reality is almost always more complex than our definitions. The important thing is to learn to ask the right questions.

rjett 16y ago

Understanding why many of these controversial diseases are problems in the first place is made a little clearer if we look at the problem through the lens of behavioural economics. Alcoholics, nicotine addicts, many obese people, sexaholics, etc place huge discount rates on future rewards so that in the present, these future rewards are almost worthless. Put another way, these people place the most value on their next item of consumption which allows them to overcome the long-term costs of their destructive behaviour or the long-term benefits to quitting (if we assume these people make an instantaneous cost-benefit analysis each time they eat/drink/smoke/etc). This sort of radical discounting behaviour has been shown to be reversible in those who seek treatment. Now, to one of the main points of the article: What constitutes an acceptable form of treatment to these gray-area diseases? An economist would probably say that you would have to consider the individual in question and then formulate a solution based on that individual's preferences, likelihood of success, and cost of change. For one obese person, gastric bypass might be the only solution between life and death. For another obese person, paying $25,000 for gastric bypass surgery might be "worth it" and allow them to change their eating habits in a way that would benefit them long-term without having to go through the anguish of months or years of diet and exercise. For another obese person with another preference set, diet and exercise would be far less costly than gastric bypass. Why bring right and wrong into the argument when looking at treatment methods? Edit: Giving the issue some further thought, some might make a value judgement as to how bad or good heavy temporal discounting is. Given the assumption that it is wrong or bad, then you could hypothesize that the American culture of consumerism has gradually conditioned our population as a whole to shift their preferences to the present, valuing the quick fix over long-term, less costly approaches.